Towards a Mentally Flourishing Scotland: Consultation as Public Action

This report results from an extensive research project examining how knowledge functions within a consultation process for a new mental health policy in Scotland. The research is part of the European Commission funded KnowandPol project which
investigates knowledge in relation to health and education policies within eight European countries. The work of the Scottish Health team throughout the project focuses on mental health policy in Scotland. Our work reported here represents the first of two case studies for ‘Orientation 2’ of the project which seeks to examine the
way knowledge is used and produced within the processes of a particular policy or public action.

The following questions guide the general KnowandPol research within Orientation 2:

• Where do the actors involved in the public action speak from? Where do they come from? Who do they talk to? What kind of relationships are they involved in?

• What do the actors involved know? What do they think they know? What types of categories do they use in their narratives? How do they assemble ideas, actors, devices, events, values in their story?

• What are the common stages/events emerging from the narratives?

• Why is it that such or such representation of reality comes to structure public action at a given time period in a given country/sector?

Case study:

In order to explore these questions we have chosen to focus on the consultation for Towards a Mentally Flourishing Scotland (TAMFS) which was launched in October
2007. This consultation was initiated to develop the next stage of the Scottish
population mental health policy - the National Programme for Improving Mental
Health and Wellbeing.
We chose the TAMFS consultation as a case study because the policy consultation
process represents a ‘critical event’ in that it serves to strip an existing policy back,
makes it justify itself and opens itself up to new discourses. It also represents the
introduction of a new form of knowledge into the policy domain and permits us to
visualise the way in which this knowledge flows through the policy community. It
allows us to examine the knowledge used by a wide range of actors in their interaction
with the policy ideas and each other. This action happens within a wide range of
settings – within many different document forms, closed meetings, pubic events, 2
private discussions and emails. This allows us to visualise how knowledge
differentially functions within these different practices.

The TAMFS consultation consisted in a series of events, documents and meetings
which responded to a government consultation document. The key ‘public’ stages of
the consultation involved a series of consultation events hosted nationally and by
local authorities, health boards and NGOs and the submission of consultation
response documents by individuals and organisations. The key ‘closed’ (internal
government and invited) stages of the consultation involved a series of meetings by a
national reference group of expert service users, practitioners and academics and of a
internal government reference group, meetings between government actors and
individual experts and a series of events with key stakeholder groups prior to the
publication of the final policy document.

Method:

We tracked each stage of the consultation process by utilising a broad mix of data
collection methods:

1. Interviews on the development of the National Programme and how the
consultation document was developed.

2. Observation of a broad range of consultation events.

3. Documentary analysis of the consultation document and support documents.

4. Documentary analysis of written responses made.

5. Observation of the National Reference Group guiding the consideration of the
consultation responses.

6. Interviews with those responsible for organising the consultation events and/or
drafting responses.

7. Interviews with those involved in drafting the final policy and action plan.

8. Documentary analysis of the final document and other documents which
informed its development.

Findings:

In order to answer criticisms about the lack of a clear model of mental health being
used in the work of the National Programme the TAMFS consultation document
introduced a new theoretical model for public mental health based around the work of
Corey Keyes and Keith Tudor. It also based itself clearly within an ‘inequalities’
framework.

Actors.

We found that different actors used different forms of knowledge in very different
ways at different stages of the consultation process:

Government actors:

Government actors set the terms of the consultation and used its involvement in order
to educate the consultation ‘public’ about their agenda for mental health
improvement. The knowledge government actors were presenting was validated
through their reference to the work of ‘expert’ and international actors and through 3
referring to peer reviewed research and statistical evidence from the use of indicators
and other measurement tools.

The Scottish Government does not create knowledge, but rather it gathered and
organised it. Its involvement in the consultation was as a hand guiding the process. It
directed how knowledge should be understood (in this case through the selection of
appropriate theory) and what types of knowledge should be gathered (consultation
events and inviting specific types of actors to contribute and through devising
instruments such as indicators to support the policy implementation). In this way it set
up the conditions in which knowledge could be created but did not generate its own
knowledge.

Practitioners:

Practitioners made up the vast majority of the ‘consultation public’ present at
consultation events. Different practitioners were invited to present examples of ‘good
practice’ at all consultation events we attended. The dialogue between practitioners
within discussion groups which followed these presentations drew on the experiential
knowledge of practitioners. This experience-based knowledge drawn from their work
– often expressed in the form of short vignettes about their practice - was ‘traded’ in a
back and forth dialogue between participants. The trading of good and bad practice
allowed the boundaries of work in the area to be ‘rehearsed’. Through the processes
of the consultation appropriate practices were therefore developed in relation to the
new policy being discussed. This process was educational in that it taught those who
would have to implement the new policy about how this might best take place. In this
way the consultation process acted as a way of cementing the new policy in the minds
of those who would have to do the work and ‘armed’ them with strategies for how the
work of the policy could be taken forward.

Practitioner knowledge did not take the form of vignettes in the consultation
responses which were submitted by mainly practice-based organisations. In the
consultation response documents practitioner organisations drew to a far greater
extent on ‘official’ evidence drawn from research reports, evaluations and statistics.
Practice based knowledge was largely absent from the rest of the consultation process
although practitioners were included in the final stakeholder discussions in order to
validate the policy before it was released. We argue that this may be as a result of the
particular practices surrounding different parts of the consultation process – because
of conventions about their use official policy documents cannot contain the type of
experiential knowledge produced and used by practitioners.

Service users:

Unlike practitioners and government representatives, service users and carers did not
give presentations on their experience at the consultation events but were most active
as participants in discussion groups. As with practitioners, the service users and carers
we observed based their knowledge on personal experience and often transmitted this
knowledge through the use of small vignettes used to illustrate a point.

Service user knowledge did not ‘travel well’ through the process. Service user voices
were present at the consultation events and reference group meetings but did not
readily move from this context into the consultation response documents. This may be
as a result of the form that service user knowledge was presented in. Like practitioner 4
knowledge personal experience is difficult to quantify and the vignettes in which
service user knowledge were presented do not easily fit within some document forms.

Expert knowledge:

The experts whose knowledge was included in the consultation are mostly public
health specialists and academics. Academic knowledge was not prominent in the
consultation events and only visualised through the presentation or citation of the
work of these experts. It was more prominently used in the reference group, which
included academics and was provided with papers and presentations by Keith Tudor,
Phil Hanlon and Carol Tannahill. The experts present a mixture of local actors who
know the Scottish ‘scene’ and international experts who provide the theoretical and
epidemiological perspectives which frame the work of the National Programme. Their
knowledge was used to validate the government’s agenda for mental health
improvement in Scotland.

Psychiatry- an absent actor:

Psychiatrists did not participate at most of the consultation events and were not
invited to do so by the government. Psychiatry has traditionally had little to do with
the day to day work of public mental health, given that its focus is on the treatment of
mental ill-health. Professional psychiatric knowledge challenges the mentally
flourishing framework, as evidenced in the response document submitted by the
Royal College of Psychiatrists, which made negative comments about the theoretical
framework underpinning the TAMFS document.

Key points:

Consultation as education:

Within the TAMFS consultation the purpose of creating a new policy seemed at some
stages to be secondary to the purpose of ‘education’ of the policy ‘public’. Different
actors used the consultation process for different educative purposes. For the
government the consultation document and events also provided an opportunity for
educating a captive audience about the issues and practices involved in the
implementation of policy and practice for population mental health. The use of
language and theory were important instruments in this work. In our discussion of
practitioner knowledge we show that for organisations hosting consultation events
these served the purpose of educating those working within their organisation or area
about the role that they had to play in doing the work of the National Programme.
This ‘education’ took place via presentations made by government, practitioners and
experts. It also occurred through the back and forth dialogue of practitioners sharing
good practice.

Through its educative function the consultation process worked to carve out a new
space for policy action which would mean an easier transition to the new policy and a
greater depth of policy awareness which would, in turn, lead to better policy
implementation. In this way we can visualise the consultation process as functioning
as the first stage of policy implementation. Consultation processes in themselves thus
act as a macro instrument of policy.

Hierarchies of evidence – theory vs. other types of evidence:

The decision to use the theory related to its status in relation to other types of
knowledge. Use of the theory was seen as a logical step for the consultation
document as it provided a justification for the policy approach taken where no other
evidence existed that would justify the policy. In the TAMFS consultation document
theory was thus used instrumentally in place of other evidence when there were no
other forms of evidence available. However, by the time that the policy and action
plan came to be written other forms of knowledge had become available which were
seen to challenge the ‘authority’ of the theory as evidence underpinning the work of
the National Programme. The creation of new statistical and other research data on
public mental health served to destabilise the dual continua theory for those
developing the policy and action plan. Theory, then, was seen as important, but was
‘outclassed’ as a form of reliable policy evidence in the face of ‘data’ sourced from
measures and indicators.

Language:

Language was used instrumentally by different actors throughout the consultation
process where different vocabularies were used or challenged in order to make
different policy arguments. Many of the arguments related to the need to develop a
shared language which could convey the themes of the policy. Using a certain kind of
language brings with it a certain kind of knowledge or theoretical perspective. Even
in the absence of formally articulated scientific knowledge, the ’right words’ were
seen by many involved in the consultation process as a key vehicle of the ’right
policy. There was a frustration amongst a range of actors about the inability for a
shared language to be developed that could simply express the theoretical basis
underpinning the work of the National Programme. A lack of a shared language was
seen to result in limited shared working around the goals of the National Programme
and a failure for the message of positive mental health to spread into other fields.
Language was thus viewed as an important instrument whose correct use would lead
to successful policy outcomes

Indicators

Our analysis pointed to a growing interest in the creation and use of statistics and,
following on from this, the development of indicators for mental health policy in
Scotland. This raises questions about why indicators and statistics are seen to have
such utility for mental health policy. It was felt that a lack of indicators meant that
particular policies and programmes could not be justified to funding bodies and
agencies because their effectiveness could not be adequately gauged. Drafts of the
final TAMFS Policy and Action Plan called for the development of new indicators for
population mental health in addition to the newly devised Warwick Edinburgh Mental
Wellbeing Scale (WEMWBS). The introduction of these new indicators extended the
boundaries of the governable space yet further. Part of the utility of the development
of the WEMWBS scale is that it marked out a new space as governable – that of
positive mental health - and this was important when the words used to express the
theory were deemed to be inadequate. Numbers were able to do what words cannot.
A set of indicators becomes the shared language that everyone can use.

Conclusions about knowledge in the TAMFS consultation:

In concluding we can list some of the variables effecting the emergence of different
types of knowledge within the consultation process:

Discourse practices – the type of practice in which a discourse is enacted depends on
what type of knowledge is prioritised. For example, consultation events give way to
embodied knowledge such as good practice or personal experience. This knowledge
is not able to be contained so easily within a highly structured document such as a
policy and action plan, where strict conventions govern what content is acceptable.

Individuals – what gets written down on paper in the end is determined to a certain
extent by who does the writing. At each enactment of knowledge within every stage
of the process different configurations of power and knowledge determine what
knowledge is included. The leadership style and personal knowledge of those in
leadership positions within the Mental Health Division determined what sorts of
knowledge were prioritised within, for example, the discussions in the National
Reference group.

Political environment – the political environment will have a ‘high order’, macro
bearing on what knowledge is prioritised in the process. For example, the SNP’s
prioritisation of the use of indicators through its National Performance Framework
meant that indicators were more highly prized than other forms of policy instrument.

Availability of instruments – in our discussion of theory we noted that there was what
could be called a ‘hierarchy of instruments’ functioning. Theory was valid evidence
for policy development only when the evidence produced by a more reliable
instrument such as, in this case, data from an indicator, was not available.